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Pediatric Imperforate Hymen Workup

  • Author: Amulya K Saxena, MD, PhD; Chief Editor: Andrea L Zuckerman, MD  more...
 
Updated: Apr 22, 2016
 

Approach Considerations

Careful physical examination combined with imaging is usually sufficient to establish the diagnosis of imperforate hymen. In certain circumstances related to the child's age and maturity, examination may need to be deferred until it can be performed with the patient under anesthesia.

Laboratory studies are not necessary in the evaluation and treatment of imperforate hymen. Tumor markers CA-125 and CA-19-9 are elevated in imperforate hymen; although these markers suggest the presence of a benign condition, they are not necessary for diagnosis.[16]

The diagnosis should not be confirmed by aspirating secretions beyond the obstruction because this procedure may result in iatrogenic pyocolpos. Instead, the diagnosis should be confirmed by performing noninvasive imaging studies (eg, ultrasonography or magnetic resonance imaging [MRI]) to determine the extent of the vaginal outflow obstruction and to diagnose other associated anomalies.

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Imaging Studies

Abdominal and pelvic ultrasonography and MRI are the cornerstones of imaging for uterovaginal anomalies. Ultrasonography provides a reliable means for rapidly diagnosing hematocolpos or hematometrocolpos (see the images below).[17]  If a complex anomaly is suspected, MRI is necessary. In addition, transrectal ultrasonography may help in delineating complex anatomy. MRI and ultrasonography also aid in excluding associated congenital anomalies of the urinary tract. Although rare, combined anomalies (ie, imperforate hymen and a transverse vaginal septum) can occur.[18]

Sagittal sonogram in an adolescent with imperforat Sagittal sonogram in an adolescent with imperforate hymen shows a distended vagina and uterus.
Transverse sonogram in an adolescent with imperfor Transverse sonogram in an adolescent with imperforate hymen shows a distended vagina immediately posterior to the bladder.
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Other Tests

Invasive examination is typically unnecessary for diagnosis. However, sedation or general anesthesia may considerably aid in the examination of anxious patients, especially young children. In the optimal situation, the use of anesthesia should be delayed until noninvasive studies are completed and until a surgeon is prepared to proceed with definitive therapy.

Laparoscopy has been recommended in some cases to evacuate pelvic and intra-abdominal endometrial material generated because of retrograde menstruation. This procedure is speculated to reduce the potential for secondary endometriosis. However, most cases of endometriosis regress spontaneously after resection of the obstructing membrane. Most cases do not require concurrent laparoscopy.

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Contributor Information and Disclosures
Author

Amulya K Saxena, MD, PhD Consultant Pediatric Surgeon, Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Healthcare NHS Fdn Trust, Imperial College London, UK

Amulya K Saxena, MD, PhD is a member of the following medical societies: International Pediatric Endosurgery Group, British Association of Paediatric Surgeons, European Paediatric Surgeons' Association, German Society of Surgery, German Association of Pediatric Surgeons, Tissue Engineering and Regenerative Medicine International Society, Austrian Society for Pediatric and Adolescent Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth A Paton, RN, MSN, NP Nurse Practitioner, Pediatric Surgical Group; Nurse Practitioner, Department of Emergency Medicine, Le Bonheur Children's Hospital

Elizabeth A Paton, RN, MSN, NP is a member of the following medical societies: American Academy of Pediatrics, American Association of Nurse Practitioners, Sigma Theta Tau International, Emergency Nurses Association, National Association of Pediatric Nurse Practitioners

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD Associate Professor of Obstetrics/Gynecology, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center

Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth Alderman, MD Director, Pediatric Residency Program, Director of Fellowship Training Program, Adolescent Medicine, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, Society for Adolescent Health and Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Martin I Herman, MD, FACEP, FAAP Professor, Department of Pediatrics, Division of Critical Care and Emergency Medicine, University of Tennessee Health Sciences Center; President, Pediatric Emergency Services Specialists, PC; Assistant Medical Director of Emergency Services, LeBonheur Children's Medical Center

Martin I Herman, MD, FACEP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, and Tennessee Medical Association

Disclosure: Challenger Corporation Ownership interest Board membership

Arlet Kurkchubasche, MD Assistant Professor, Department of Surgery and Pediatrics, Brown University and Hasbro Children's Hospital

Disclosure: Nothing to disclose.

References
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  3. Congenital abnormalities of the female reproductive tract. Mishell DR, Stenchever MA, Droegemueller W, et al, eds. Comprehensive Gynecology. 3rd ed. St Louis, Mo: Mosby-Year Book; 1997.

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  13. Nagai K, Murakami Y, Nagatani K, Nakahashi N, Hayashi M, Higaki T, et al. Life-threatening acute renal failure due to imperforate hymen in an infant. Pediatr Int. 2012 Apr. 54(2):280-2. [Medline].

  14. Winderl LM, Silverman RK. Prenatal diagnosis of congenital imperforate hymen. Obstet Gynecol. 1995 May. 85(5 Pt 2):857-60. [Medline].

  15. Ogunyemi D. Prenatal sonographic diagnosis of bladder outlet obstruction caused by a ureterocele associated with hydrocolpos and imperforate hymen. Am J Perinatol. 2001. 18(1):15-21. [Medline].

  16. Sak ME, Evsen MS, Soydinc HE, Sak S, Yalinkaya A. Imperforate hymen with elevated serum CA 125 and CA 19-9 levels. J Reprod Med. 2013 Jan-Feb. 58(1-2):47-50. [Medline].

  17. Ayaz UY, Dilli A, Api A. Ultrasonographic diagnosis of congenital hydrometrocolpos in prenatal and newborn period: a case report. Med Ultrason. 2011 Sep. 13(3):234-6. [Medline].

  18. Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg. 1999 Oct. 34(10):1555-6. [Medline].

  19. Frega A, Verrone A, Schimberni M, Manzara F, Ralli E, Catalano A, et al. Feasibility of office CO2 laser surgery in patients affected by benign pathologies and congenital malformations of female lower genital tract. Eur Rev Med Pharmacol Sci. 2015. 19 (14):2528-36. [Medline]. [Full Text].

 
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Embryologic origin of the hymenal membrane.
Neonate with a bulging perineum due to mucocolpos.
Sagittal sonogram in an adolescent with imperforate hymen shows a distended vagina and uterus.
Transverse sonogram in an adolescent with imperforate hymen shows a distended vagina immediately posterior to the bladder.
 
 
 
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